Acute pancreatitis complicates approximately 1 in 1000 pregnancies, with incidence increasing in late gestation and gallstone disease the most common aetiology. Pancreatitis is typically associated with stress hyperglycaemia; severe hypoglycaemia is rare. While isolated cases have been reported in non-pregnant and postpartum patients, antepartum endogenous hyperinsulinaemic hypoglycaemia with pancreatitis is rarely described.
We present a 27-year-old primigravida with a previously uncomplicated pregnancy, normal oral glucose tolerance testing and no history of dysglycaemia, who presented at 34+4 weeks’ gestation with severe epigastric pain, nausea and vomiting. Imaging demonstrated acute gallstone pancreatitis; bloods showed amylase 3627 U/L, lipase 3182 U/L and triglycerides 4.0mmol/L. Despite initial biochemical improvement, she developed persistent tachycardia, hyperlactataemia, coagulopathy, profound hypoalbuminaemia and recurrent symptomatic hypoglycaemia, with a nadir serum glucose of 1.9 mmol/L requiring intravenous dextrose. Differential diagnoses included hyperinsulinaemic and non-hyperinsulinaemic endocrine pathologies, acute fatty liver of pregnancy, hepatic failure and systemic inflammatory response syndrome. Subsequent biochemical testing during hypoglycaemia (glucose 2.4 mmol/L) demonstrated inappropriately elevated insulin 19.9 mIU/L and C-peptide 2332 pmol/L, confirming endogenous hyperinsulinaemia.
Given progressive maternal metabolic deterioration, a multidisciplinary decision was made to proceed with emergency Caesarean delivery at 36 weeks’ gestation. Postpartum imaging confirmed severe necrotising gallstone pancreatitis with peripancreatic collections. Hypoglycaemia, hyperlactataemia and coagulopathy resolved following delivery despite ongoing pancreatic disease.
This case highlights a rare metabolic manifestation of severe pancreatitis in pregnancy and demonstrates that maternal clinical deterioration may occur despite improving pancreatic enzyme concentrations. Careful glucose surveillance and multidisciplinary management are essential when atypical metabolic complications arise.